Healthcare Value Analysis

Healthcare Value Analysis Professionals at the Infection Prevention Table

By Karen Niven, MS, BSN, RN, CVAHP

Editor's note: This column originally appeared in the September issue of Healthcare Hygiene magazine.

If we have learned nothing else in the last 18 months amid the pandemic, we have learned the importance of a strong value analysis process that supports our clinical teams, our financial teams, our operational teams, and our leadership teams. Healthcare supply chain has been challenged in 2020-2021 like no other time previously. We must use these painful learnings and events to embrace a value analysis process that is embedded in our organizations. The value analysis process then becomes “the way we do things” instead of “the things we do.” To be best prepared for our next challenges -- and there will be a “next challenge” -- we need to use our learnings and this time to elevate value analysis in our healthcare organizations to have a seat at these table. Value analysis professionals must be at the table -- at the clinical table, at the operational table, at the financial table, at the leadership table, and even at the infection prevention table. So, what does it mean to be at these different tables?

Being at the clinical table means as the clinicians consider the products to provide care for all patients, they use the evidence based clinical value analysis process as a part of their decision. Defined by the Association of Healthcare Value Analysis Professionals (AHVAP), this a “process for evaluating healthcare services for clinical quality and cost effectiveness.” This includes the review and evaluation of clinical evidence as these decisions are under consideration. Value analysis has been described as, “a transforming methodology in healthcare that helps providers select products and services, not on personal preference, but on the best value it brings to the organization and its patients.”

What higher purpose than this do clinicians have to their patients and the care they provide?

Being at the operational table means the involvement of all levels of practitioners, including physicians. This involvement is especially important in the evaluation of new technology and can drive unparalleled value to the new technology assessment. In organizations where physician led value analysis is in place, many of the preference products, such as surgical mesh or surgical energy, can be objectively reviewed and decisions made that supports clinical quality and cost effectiveness. These value analysis discussions are paramount in today’s environment and contributed to outcome excellence and cost containment.

What higher purpose than this do operational leader have to their organizations?
Being at the financial table means the value analysis professional is included in the financial decisions made by the organization. This would include both planning and executing the organization’s financial budgets and plans. A senior leader in my organization said, “We need to evaluate the cost of the care and not dwell on the price of the product.” And what better professional to support the financial teams in that evaluation than the organizations value analysis professionals?

What higher purpose that this do financial leaders have to their organizations and patients?
Being at the leadership table means that in addition to the other organizational leaders, value analysis professionals having a seat at the table allows them to contribute their expertise in conjunction with the AHVAP Value Analysis Statement of Purpose: “Healthcare value analysis contributes to optimal patient outcomes through an evidenced-based systematic approach to review healthcare products, equipment, technology and services. Using recognized practices, organizational resources collaborate to evaluate clinical efficacy, appropriate use and safety for the greatest financial value.”©

What higher purpose than this do leaders have to their organizations and patients?
Being at the infection prevention table means the value analysis professional works with their infection prevention and control professional when evaluating products and make appropriate selection decisions based on sound infection prevention and control (IP&C) guidelines. As a previous surgical services director, I have had the invaluable experience of being included in discussion with IP&C professionals and had the opportunity to invite other perioperative staff as well. In the surgical services practice arena, many times the most valuable voice is the voice of the team in the room. They are the voice of patients who may be unable to speak for themselves. These team members know how to provide the best quality care behind the operating room (OR) door. And this is the voice we need in the value analysis discussions and decisions.

We also must embrace the entire perioperative patient care continuum, including pre-op, intra-op and post-op for patient normothermia. To accomplish this quality patient outcome, our value analysis team should have those patient care areas included in these discussions. As we work across this continuum on the perioperative infection prevention, we need to have full team decisions on the following and explore a value analysis strategy including:
• Analyze current products related to SSI
• Infection prevention/quality working with supply chain to align on product decisions
• Opportunity to combine products for increased value
• Risk share contract solution availability to warrantee prevention

What higher purpose that this do infection prevention leaders have to their organizations and patients?
As the Hippocratic Oath states, “first do no harm.” What a life-changing opportunity value analysis professionals have at this pivotal time in the delivery of quality healthcare. The opportunity to be part of the development, delivery and healthcare changing value analysis process. You have the opportunity to be a part of this journey. So, join value analysis professionals on this amazing industry changing ride.

Karen Niven, MS, BSN, RN, CVAHP, is the Southeast Region director for AHVAP as well as director of Performance Groups for Premier Healthcare Alliance.

Value Analysis Partnership and the Approach With Surgical Services Disruption

By Karen Tucker, MSN, RN, NEA-BC; Gloria Graham DNP, RN, CVAHP; and Heather Waters, MSN, RN

Editor's note: This column originally appeared in the August 2021 issue of Healthcare Hygiene magazine.

Healthcare is recognized for patient care and the outcomes provided by professionals to ensure safe and positive outcomes. To support and maintain positive outcomes for patients and staff, the right supplies and equipment must be available at the right time for the right patient. This area of supply and equipment known as supply chain management/value analysis, is not top-of-mind to caregivers as a potential threat to patient care or daily operations. The lack of equipment or supplies has an impact on operations by delaying care, patient safety, patient outcomes, and ultimately can create waste and harm in the system (Kritchanchai, et al., 2019). Mitigating the risk of patient care disruption is achieved through collaboration with supply chain and value analysis. The Association of Healthcare Value Analysis Professionals (AHVAP) recognizes value analysis as the process that evaluates products to improve patient outcomes through an evidence-based approach while also assessing safety, efficiency and the financial impact.

Collaboration Through the Pandemic
With the last year, healthcare systems and staff recognized how critical the need for equipment and supplies are. Impact of the pandemic and the supply strain highlighted the need to partner with frontline staff, supply chain and value analysis (VA). A basic understanding of this work and collaboration is key to connect the importance to patients and staff. Access and availability to appropriate supplies and equipment for patient care improves workflow and work satisfaction for staff and better outcomes for the patient. Supply chain’s focus in healthcare is to provide appropriate equipment or supply to the patient or staff without causing disruption, or harm to the patient (Emmett, 2019). The need for supplies can be something as simple as gloves and gowns or a critical piece of medical equipment to sustain life for a patient. All supplies within a healthcare system require the right key stakeholders to ensure the process is efficient and the correct supplies are in place from a practice and safety perspective.

Interdisciplinary Approach with Disruption in Supply
A disruption in the supply or equipment process can have negative outcomes. Frontline staff expectations are to have access to supplies and equipment when needed, yet most lack understanding or appreciation of value analysis/supply chain processes. During the COVID-19 pandemic, healthcare systems were faced with a pace of high demand for supplies and equipment coupled with production issues. As a result, hospital leaders and frontline staff quickly realized the importance of supply chain and value analysis impacts and disruptions to staff and patients based on this critical service.

Through the support of VA staff, staff was able to quickly assess and evaluate the needs, assess new products as alternates in conjunction with being mindful of the financial impact. Organizations without a strong VA structure and coordinated team likely experienced even more challenges and struggles to work through as they established contingency plans and set staff at ease with the plans.

Operational Impact
Throughout the last year, the disruption of supplies and equipment was felt by the frontline. All patient care areas were monitored and assessed on an ongoing basis for impact. Some areas of focus during this time were personal protective equipment (PPE) allocations, decrease in volume of specialty supplies, and basic inventory of items causing modification of standard work.

VA staff collaborated with surgical services with PPE allocations due to low inventory during the COVID-19 pandemic for the following items:
• Gowns: Determining the correct level gown and style for wear
• Gloves: Finding alternative manufacturers for the different surgeon needs
• Shoe Covers: Finding the right floor grip/non-slip, universal size and fabric for wear
• Bouffant/skull caps: Finding the correct thickness and size to meet a universal acceptance

As manufacturers attempted to maintain inventory for high-use products, it came with a price to other lower-volume products such as pediatric specialty items. This disruption ultimately led to discontinued items, where the VA staff worked to find alternative items that were presented to the surgical teams. This process was multidisciplinary with VA staff and key stakeholders of the surgical services teams reviewing the product, cost, and outcomes of the alternate product. At times due to patient or special design needs, supplies and alternatives were not available, which created the need for a practice modification provided by the clinicians. Some of these items included:
• Urinary stents
• Cath Lab Quick Fill Straw
• Stapler
• Miscellaneous catheters

The daily perioperative maintenance was also affected during this time, creating taskforce assistance to plan and modify a standardized work process.
• Large sharps containers were added in as a pandemic/critical item
• Disinfectants—weekly par and recycling of containers due to low inventory

There is a value and appreciation for value analysis to work in partnership with frontline operational teams as a critical voice. Through partnering with frontline leaders, both medical and nursing, and other key stakeholders, VA professionals are able to make the best decision for alternate supplies. Any resulting practice changes are decided by the interdisciplinary team, ensuring that any changes are evaluated keeping patient and employee outcomes the priority.

Karen Tucker MSN, RN, NEA-BC, is assistant vice president at Cincinnati Children’s Hospital Medical Center.

Gloria Graham DNP, RN, CVAHP, is a clinical value analyst at Cincinnati Children’s Hospital Medical Center.

Heather Waters MSN, RN, is a clinical value analyst at Cincinnati Children’s Hospital Medical Center.

Emmett D. (2019) Supply chains in healthcare organizations: Lessons learned from recent shortages. Hospital Topics. 97(4), 133-138.

Kritchanchai D, Krichanchai S, Hoeur S and Tan A. (2019) Healthcare supply chain management: Macro and micro perspectives. Log Forum, 15(4), 531-544.

Healthcare Textiles, Laundry and Infection Prevention Programs in Ambulatory Care

By Melanie Miller, RN, CVAHP

Editor's note: This column originally appeared in the July 2021 issue of Healthcare Hygiene magazine.

The recent pandemic begged the question, “Are we doing enough to manage ambulatory care textiles?” Ambulatory surgery centers (ASCs), like healthcare organizations, contract with laundry processors. Laundry processors are expected to follow “hygienically clean” linen standards compliant with the Association of Linen Management (ALM) and TRSA. Additionally, the Association for Professionals in Infection Control and Epidemiology (APIC), has developed standards for ensuring that laundry processors comply with stated recommendations for collecting, transporting, sorting, washing, drying, staging and return delivery to the user.

The pandemic opened up Pandora’s box and the world was suddenly introduced to the concept of disposable and reusable personal protective equipment (PPE) during daily news briefings. Within a few days, the public was notified by news media that PPE and medical commodities were in short supply across the country due to lack of basic raw products and dramatic COVID-19 shutdowns internationally.

Laundry processors were negatively affected by the worldwide pandemic, as were HCOs and service industry businesses alike. When restaurants and service providers were placed on hiatus, laundry processors in both the healthcare and service industries experienced immediate loss of business and revenue. This loss resulted in downstream impacts including, but not limited to, personnel layoffs and laundry closures and shutdowns. If a laundry processor was fortunate to have both service and healthcare organization clientele, it fared better during the pandemic.

Understanding the operational challenges and reusable/disposable product shortfalls throughout the pandemic is important as we begin to dissect infection prevention programs related to textile management in the ambulatory care setting.

Many ASCs were shuttered during the pandemic due to the “hold” on elective procedures. It is estimated that ambulatory centers lost 60 percent of patient throughput at the height of the pandemic.

For those ASCs that remained open, ambulatory service leaders learned quickly that remaining nimble and mid-course correcting when confronted with lack of disposable PPE was key to staying afloat. Leaders quickly contacted their supply chain, purchasing and value analysis colleagues to help them source appropriate reusable PPE.

This was not an easy task. For years, reusable PPE was talked about as a substantive alternative to waste, reducing our carbon footprint and improved sustainability but HCOs were not sold. Fast-forward to disposable shortfalls and drastically reduced allocations without notice. Immediately reusable suppliers went into overdrive trying to produce reusable PPE to meet the new and growing need.

The challenge was which standards were to be followed and would the reusable PPE meet the current published standards. Additionally, would the PPE pass the hygienically clean requirements, including wash cycle validation and certification by recognized testing industry leaders.

Again, ambulatory care leaders looked to supply chain, specifically, value analysis leadership to determine best practice and the required testing and certification to ensure that reusable PPE met and exceeded ANSI/AAMI and Centers for Disease Control and Prevention (CDC) guidelines, including AATCC 42/127, Class I Flammability, Anti-Static and Wash Cycle certification.

Value analysis committees across the country had a new direction sourcing gloves, masks, gowns, respirators, ventilators, and other critical life-saving equipment not in that order. Whereas in the past, a product review might take four to six months, aligning with project management guidelines, communication and collaboration, addressing value analysis methodology, maintaining best business and professional, ethical, and financial practices there simply was not enough time.
At the same time, gray market brokers capitalized on the challenging state of events and went to market with products that did not meet minimum performance standards.

The world of inpatient and ambulatory care was turned upside down in some counties and states due to lack of disposable and reusable supplies, including sheets, towels, patient gowns, isolation gowns and laundry bags.

Leading healthcare laundry and textile organizations jumped to attention and developed webinars and information sharing blogs to help educate HCO staff and healthcare apparel manufacturers. Laundry processors realized that however bleak, downtime was a blessing and instituted new and improved facility cleaning standards, equipment preventive maintenance review and safety training for all staff with an eye to minimizing employee exposure and risk in the workplace.

APIC, through its regional and national leadership forums, helped educate healthcare epidemiologists and value analysis professionals about the most up-to-date standards for disposable and reusable textile management, including PPE and isolation gowns.

When the critical pandemic situation improved, states slowly began reopening. Laundry processors across the country breathed a sigh of relief. They could reestablish their processes and ensure hygienically clean compliance. Many of the laundry processors used the downtime to review their operational policies and procedures to ensure compliance with state directed healthcare textile standards.

Laundry processors knew that going forward their key to future success was engaging the healthcare organizational leaders in inpatient or ambulatory settings to showcase their operational improvements that would result in improved throughput and service post pandemic.

Taking a fresh look at relationship building, many laundry processors leaders reached out to APIC, the Society for Healthcare Epidemiology of America (SHEA) and hospital leaders, and through virtual and in-person teams, reviewed policies and procedures to ensure that the local laundry processors were compliant with hygienically clean standards. Laundry processing leadership recognized the benefits of weekly, monthly, and quarterly check-in with their inpatient and ambulatory clientele.

Reviewing laundry assessment tools resulted in streamlining internal processes and illuminating the partnering benefits with key leaders in linen, value analysis and infection prevention and control (IP&C) in the inpatient and ambulatory setting.
Going forward, a hybrid model appears to be a thoughtful, planful approach to manage ambulatory textiles. Developing service guidelines that encourage patients to wear appropriate clothing to outpatient appointments, imaging procedures and surgical procedures minimizes the need for disposable or reusable linen.

Ambulatory care teams can focus on reusable and disposable textile patient needs that ensure patient dignity, comfort, and best experience. A refreshed approach to ambulatory textile oversight will help manage cost, reduce textile handling, eliminate waste, align with IP&C protocols, and contribute to overall sustainability programs encouraged by healthcare leaders.

Melanie Miller, RN, CVAHP, is a founding member and past-president of the Association of Healthcare Value Analysis Professionals (AHVAP), and vice president/chief strategy officer of Silver Lining Apparel.



Infection Prevention and Value Analysis Forge Even Stronger Relationships

By Barbara Strain, MA, CVAHP

Editor's note: This column originally appeared in the June 2021 issue of Healthcare Hygiene magazine.

Prior to 2020 the participation of infection prevention and control (IP&C) was a key element of successful value analysis (VA) initiatives, but the role took on even more significance because of the COVID-19 pandemic.1 SARS-CoV-2 was a novel virus in the most complete sense. It had not been previously isolated, its mode of transmission was not completely understood, nor were there laboratory tests to detect the presence of the virus itself nor testing for antibody levels to determine immune status. Hot spots were occurring with the rapid surge of symptomatic, sick, and dying patients in healthcare institutions around the world. It became obvious very quickly that there were competing challenges that effected all aspects of the path forward: staff safety, vetting, sourcing, and conserving supplies, and patient care.

To quote an IDN that was interviewed for an Association of Healthcare Value Analysis Professionals (AHVAP) podcast in May 2020, “ensuring the safety of the front-line staff” was essential. To stay abreast of the fast-changing CDC guidelines to assure the most appropriate personal protective equipment (PPE) was available to the clinical and support staff, infection preventionists (IPs) conducted real-time assessments of how care was being provided. It was quickly determined that the usual method of triage and assigning patients to open ICU beds was not an optimal model, so IP&C recommended cohorting patients and staff to dedicated ICUs as the best scenario.

In this newly created, dynamic care environment, staff could don gowns, masks and head coverings, and wear them for longer periods of time without removing, and, in some situations, donned coveralls over basic PPE to conserve use.

Each decision was made based on communication with value analysis professionals (VAPs) who are the clinical connection to hospital supply chain (SC) operations. Before practice was changed or procedures edited, IPs and VAPs conferred on availability of supplies to ensure that new plans could be carried out. SC would provide timely “run rates” indicating how fast high-demand supplies were being used and forecast how long current stock of supplies would last as well as when additional stock would arrive. Using their knowledge, skills, and abilities IPs and VAPs created lists of the key characteristics of the high-demand supplies which reduced the time to locate best-fit equivalents to ensure uninterrupted care.

When it became clear that the global supply of non-powered respirators/N95 masks were not keeping up with demand and were met with fit-testing constraints, the CDC decided to allow either third-party vendors to provide reprocessing services of these masks or allow hospitals to perform reprocessing on site by specific approved methodologies. VAPs gathered the information to determine which option(s) had the shortest implementation timeline for teams led by IPs along with staff from biomedical engineering and facilities, and executive leadership could make easy-to-operationalize, safe decisions.

Other conservation practices included IP&C approving the use of extra-long IV-intravenous tubing connected to the patient to allow respective IV pumps to function outside the room. This measure decreased the number of times a fully donned nurse had to go into a patient’s room to monitor and adjust the settings.

Even before it was confirmed by CDC and NIH that patients were highly contagious, IPs, chief medical officers and chief nursing officers instituted negative-pressure room policies. With the assistance of facilities management professionals, plans were put in place to convert regular patient rooms, emergency department holding rooms, and other appropriate care-spaces into negative-pressure conditions where physically possible. This kept contagious viral particles from entering non-care areas or areas where non-healthcare workers or those not wearing powered or non-powered N95 masks were present.

Prior to the availability of certain drugs, convalescent serum or other treatments were available for patients whose lung capacity and breathing conditions deteriorated, a large percentage were put on ventilators.2 In most hospitals there are fleet of ventilators for a normal level of patient need, plus a reserve amount for unexpected circumstances -- but it is not equipped to handle the high, long-lasting surge caused by COVID-19. VAPs were called into action to vet a new set of criteria for ventilator tubing and hoses as well as connectors for their own fleets of ventilators and for other models that may have been rented or purchased. Some hospitals that had both a space constraint and ventilator shortage adapted what the FDA referred to as “multiplexing ventilator tubing connectors, also known as ventilator splitters, in situations in which no alternatives for invasive ventilatory support are available,” and provide a considerations list that health care providers and facilities should review.3

In extreme situations, patients were placed on ECMO-extracorporeal membrane oxygenation treatment, where oxygen is delivered directly to the patient’s bloodstream to bring relief to breathing impairment. Hospitals with specially trained staff and ECMO equipment to support such treatments put additional strain on capacity to use this practice as patient demand rose above normal. Ventilators and ECMO come with their own set of issues that IP&C monitored closely along with anesthesiology and respiratory therapy to assure that precautions were in place to prevent development of ventilator-associated pneumonia, bloodstream and other infections.

Since the number of COVID-19 cases have ceded to lower, manageable levels, hospitals have begun to open their care services to pre-2020 conditions. Lessons learned from the pandemic informed how the delivery of care can be effective through:
· Reviewing and updating emergency operations, infection prevention and control, and institutional & departmental policies,
· Creating a response handbook based on critical triggers which include but are not limited to:
- Monitor CDC, WHO and other global health watchdogs by Emergency Preparedness Committees and IP&C
- Establish a global raw materials, work-in-progress and finished goods alert system and report dashboard
- List key departments – such as IP&C, VAP, SC -- who should be notified based on mutually agreed upon on-hand and available-to-purchase product thresholds
· Identifying top product needs in incident categories and develop a list of key characteristics for each product to facilitate quick decision-making. For example, for air born contagion: non-powered or powered respirators, face shields, protective gowns, oxygen masks/tubing, list of key characteristics each product type
· Adopting the communication style and methods that worked during Covid19 as your organization’s everyday method.

The COVID-19 pandemic has taught us many lessons but the importance of interprofessional relationships has been undeniably one of the best learned.

Barbara Strain, MA, CVAHP, is an independent healthcare value consultant whose clients range from new emerging and disruptive technology to Fortune 500 companies. Strain honed her expertise over a 40-year career as a healthcare provider across multiple specialties first in clinical laboratory operations, microbiology, disinfection and sterilization, and infection control, then as a value analysis professional. She is a founding member and past-president of the Association of Healthcare Value Analysis Professionals (AHVAP).